Summer 'thoughtlets' on dry eye and other topics

Issue: August 25, 2015

ByDarrell E. White, MD

It’s summer time. Writers and readers naturally turn to lighter fare, intellectual sangria in a red Solo cup to the winter’s Sinskey Claret in Riedel — RIP, Dr. Sinskey. Growing up in New England, whatever beach reading we might have done was bookended by the sports pages in the Boston Globe. Sportswriters taught us all how to write. Each week the great Bob Ryan would pen a Sunday column filled with little snippets of his thoughts about the state of sports and the world in general. No one with literary aspirations dreamed of writing the Great American Novel; we all just wanted to write for the Globe or Sports Illustrated. I’m no Leigh Montville or Tim Layden — heck, I may not even be Mitch Jackson or Uday Devgan — but with a nod to Bill Reynolds of the Providence Journal, here is the fulfillment of a lifelong dream.

Once again I was on call for the very large local hospital’s ER in the month of July. In my nearly 30 years of life with “MD” stuck after my name, I have covered the 4th of July weekend roughly 25 times. Even more than New Year’s Eve, humanity collectively clicks the common sense button to the “off” position on Independence Day. Every year I see everything from ruptured globes to corneal burns from cigars and sparklers to poison ivy from that long-neglected, pre-party yardwork to-do list. Once again, Cleveland hit for the cycle this year.
I am finding it nearly impossible to obtain an appointment with a dry eye expert at an academic institution. No matter how much experience you have, sometimes you just get stuck and you need a little help. Good luck with that. I don’t know if professors are that busy or if they really do not like dry eye. (I have certainly written often enough about how hard it is to take care of dry eye patients.) July is especially tough navigating the gauntlet to get a consult, trying to convince a newly minted first-year ophthalmology resident that his or her equally shiny new fellow should take a phone call from the wily 25-plus-year experienced private practice vet, asking for permission to schedule a consult.
This month’s quiz: What was the PERK study, and why is it important to every ophthalmologist and every medical device company that works in our space? Bonus points for naming the principal investigator. No one over the age of 45 years is allowed to play. Answer below (and a hint to come).
What’s on your summer reading list? There must be some science fiction, right? You are an ophthalmologist. You use lasers that make matter literally cease to exist. You must have been a science fiction buff at some time in your life. The Martian by Andy Weir has to be on your list. Real, hardcore science wrapped into a suspense story, with just enough plausibility that you hope the folks at NASA read it. I left my copy for you at the hotel at the ACES meeting. Careful: NSFW language, starting with the first sentence.
When you have a hammer, everything looks like a nail. You’ve heard that one before. We have been having all kinds of success with LipiFlow (TearScience) for our meibomian gland dysfunction/evaporative dry eye patients. It works so well that it’s tempting to consider it for every dry eye patient. I find myself reminding staff, visiting docs and industry folks that we are still a dry eye practice that offers LipiFlow, not a LipiFlow practice. Even the most effective hammer doesn’t work as well if you encounter a screw.
My mother-in-law is responsible for my deep interest in dry eye. All full of myself as a new cutting-edge surgeon, I performed radial keratotomy (RK) on my mother-in-law in the early ’90s. Although she was 20/20 uncorrected in both eyes postop (I’m a hero!), the RK also unmasked a vicious dry eye problem that caused terrible photophobia (I’m a goat!). Sandy commuted east to work and west to go home, reminding her of her son-in-law at least twice a day, every day. You can imagine how hard I worked to figure out the dry eye thing.
There is no longer any question about the use of tear osmolarity in the diagnosis and treatment of dry eye. It’s a done deal. Tear osmolarity is a necessary and essential component of a dry eye practice, and you simply cannot use best practices in the field without it. This is apparently a surprise to the American Academy of Ophthalmology, which has still not revised a Preferred Practice Pattern that questions the medical necessity of tear osmolarity. A single sentence in an out-of-date when it was originally published PPP is causing all kinds of mischief. Come on, folks. It’s time to fix this.
While I’m on the subject of the AAO, why is our largest representative professional organization backing Maintenance of Certification? Or even the retaking of the general ophthalmology boards for all ophthalmologists? I am a cataract and LASIK surgeon with a deep interest in dry eye. I do more and more of less and less, and what I do, I do better every year. When I am faced with a complex pediatric case, I don’t rack my brains for the correct approach per the next board exam — I call David Granet. Why is anyone proposing testing a retinal surgeon about the ninth most common corneal dystrophy? What possible benefit is there to me or my patients if I know the specific mitochondrial genotype of the several Leber’s congenital optic neuropathy subtypes? I can send my patient to Greg Kosmorsky, the local academic neuro-ophthalmologist, who by the way is easier to get in to see than the academic dry eye specialist. The retina guys and gals should boycott MOC, and the rest of us should follow.
Quiz answer: The Prospective Evaluation of Radial Keratotomy, lead author the late and much loved George Waring III. The PERK study established the viability of elective refractive surgery and laid the groundwork for the studies of all subsequent refractive procedures. Without the rigor applied by Dr. Waring and his co-authors, it would have been impossible to consider any subsequent elective procedure on “healthy eyes.” Every time you sit down to do LASIK, you are riding the coattails of a giant.

That’s a wrap, Bucky. Don’t forget the sunscreen when you hit the beach for some summer reading. The most current research suggests that it won’t necessarily prevent skin cancer, but you’ll thank me when you hop in the shower to rinse off the sand.

For more information:
Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.

Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations and on the speakers board for Bausch + Lomb and Allergan.